Basic Information
| Provider Information | |||||||||
| NPI: | 1538300579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOPER UNIVERSITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2626 HADLEY DR | ||||||||
| Address2: | |||||||||
| City: | PENNSAUKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081093630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562205761 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2009 | ||||||||
| LastUpdateDate: | 03/22/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIXON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8562205761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | HS000204L | 01 | NJ | AMERIHEALTH | OTHER |